We Are Tough And Ornery

Michael:

If we are pragmatic then we must see that we are indeed “going nowhere”, as you suggest. There must me a paradigmn shift. The fact that the chiropractic market share hovers around 3-5% – down from 15%, a mere decade ago – is the writing on the wall. For us to gain cultural authority, trustworthiness and legitimacy, we MUST, once and for all, distance ourselves from metaphysical,quasi-religeosity and “magical thinking” of the unsubstantiated “Subluxation Complex”. A premise agreed upon merely by CONSENSUS, NOT Science!

Dr. Painter, surprisingly, hangs onto the the very premise that will be our demise in the scientific, evidence-based health care community – the premise that relagates us to the level of the charlatan and huckster, closing the door to the tsunami of potential chiropractic patients presently under the control of mainstream medicine. When will we come to grips with reality?

There is much we can get side-tracked on. I prefer to consider the fundamentals of our problem and in doing so get beyond the constant lobbying efforts to bamboozle the legislatures to legislate in our favor based upon false premises!

Despite chiropractic’s longevity, the profession has not succeeded in establishing cultural authority and respect within mainstream society, and its market share continues to dwindle. I am concerned that the common perception (which is well supported, in my experience) that chiropractors are only interested in “selling” a lifetime of chiropractic visits may be one of the primary factors behind our low standing in the minds of members of the public [1]. The recommendation for repetitive life-long chiropractic treatment compromises any attempt at establishing a positive public health image and needs to change. Public health is ultimately about self-empowerment and teaching people how to take care of themselves, with an emphasis on prevention and health maintenance. The chiropractic profession should adopt the American Public Health Association’s (APHA) scientifically-grounded emphasis on nutrition and exercise as the “keys to wellness”
I see the future chiropractor as a “non-surgical spine & musculoskeletal specialist”, enjoying full cultural authority, legitimacy and trustworthiness – but only under the following circumstances:

1) Chiropractic must abandon the Subluxation as a foundational premise.

The maxim in the computer world is: Garbage in, garbage out. Consequently, if we present a false premise, any conclusions based on this premise must also be false, to wit, the subluxation! The chiropractic subluxation stands pretty much today as it did at the dawn of the 20th century: an interesting notion without validation.

The chiropractic profession has an obligation to actively divorce itself from metaphysical explanations of health and disease as well as to actively regulate itself in refusing to tolerate fraud, abuse and quackery, which are much more rampant in our profession than in other healthcare professions [2.] This must be done on an individual practitioner basis as well as by the political, educational and regulatory bodies. In this way the profession can fulfill its responsibility to the social contract. This will dramatically increase the level of trust in, and respect for, the profession from society at large.

We must finally come to the painful realization that the chiropractic concept of spinal subluxation as the cause of “dis-ease” within the human body is an untested hypothesis [3]. It is an albatross around our collective necks that impedes progress. There can be no unity between the majority of non-surgical spine specialist chiropractic physicians and the minority of chiropractors who espouse metaphysical, pseudo-religious views of spinal subluxations as “silent killers” [4]. The latter minority group needs to be marginalized from the mainstream majority group, and no longer should unrealistic efforts be made toward unification of these disparate factions within the profession.
The chiropractic profession must establish a clear identity and present this to society. In the beginning, DD Palmer invented a lesion, and a theory behind this lesion, and developed a profession of individuals who would become champions of that lesion. This is not what credible professions do. A credible profession is one that is established by society to meet a need that society itself has decided must be met [5]. Based on all the evidence regarding chiropractic practice and education, there is only one societal need (but it is a huge one) that chiropractic medicine has the potential to meet: non-surgical spine care. Our education and training is focused on the spine, and clearly if there is a common bond among all chiropractors, it is spine care [6.]

While there are a variety of practitioners who offer spine care (physical therapists, osteopaths, movement specialists, and massage therapists) there is no physician-level specialty that has carved a niche as society’s one-and-only non-surgical spine specialist whose expertise is focused on the diagnosis and management of spine disorders.

2) Chiropractic education must be science-based, must be standardized, and must fall under the auspices of state universities.

One of the problems that are encountered frequently in our chiropractic educational institutions is the perpetuation of dogma and unfounded claims. Examples include the concept of spinal subluxation as the cause of a variety of internal diseases and the metaphysical, pseudo-religious idea of “innate intelligence” flowing through spinal nerves, with spinal subluxations impeding this flow[18]. These concepts are blatantly lacking in a scientific foundation [3][7][8]and should not be permitted to be taught at our chiropractic institutions as part of the standard curriculum. Much of what is passed off as “chiropractic philosophy” is simply dogma [9], or untested (and, in some cases, untestable) theories [3] which have no place in an institution of higher learning, except perhaps in an historical context. Faculty members who hold to and teach these belief systems should be replaced by instructors who are knowledgeable in the evidence-based approach to spine care and have adequate critical thinking skills that they can pass on to students directly, as well as through teaching by example in the clinic.
Ideally, the profession must undergo its own version of the Flexner Report that medicine underwent, and/or the Selden Commission Report and Educational Enhancement Project that podiatric medicine subjected itself to. That is, we must take a critical look at our educational institutions, find what is substandard, correct those deficiencies and standardize education across the board. Additionally (and this is essential), chiropractic education (manual medicine, if you will) must eventually merge with state university medical schools.
The long term vision must be to integrate fully with mainstream medicine through the elimination of private, self-serving, tuition-based chiropractic colleges (I mean so-called, “Universities” –“whatever you want we’ll make up the course and offer it to you, as long as you pay, pay, pay the tuition…and once you do that we’ll make up a “Certification” course, where you’ll pay some more, and then a “Diplomate” course, where you’ll pay even more, and then you’ll have to keep these certifications up to date with yearly courses and conferences…. blah, blah, blah…..!), and the establishment of chiropractic manual medicine departments under the support of the state university system, which, in and of itself, the university will attract a higher caliber chiropractic student, who will already have an entrance B.S. degree, and who will undertake the basic sciences together with his/her medical counterpart, which will consist of 4 years of standardized science-based education. Understandably, there will be unavoidable intellectual collaboration, discussion and the understanding of the roles of each health care provider in the public domain.
The second phase of the student’s education will commence at the termination of the basic science educational stage, whereupon the medical student will follow his/her studies in allopathic medicine, and the chiropractic student will pursue his/her chiropractic studies of an EVIDENCE-BASED, STANDARDIZED curricula for the following 4 years. Upon matriculation, both medical and chiropractic graduates will undertake and complete appropriate internship and residency programs. Graduated Chiropractic Physicians will follow a 3-year residency: Internal Medicine (1 year) and Orthopedics/Physical Medicine & Rehabilitation (2 years).

It is essential that the chiropractic profession establish hospital-based residencies [10]. There is a significant void in how chiropractic graduates develop any meaningful hands-on clinical experience with real patients in real life situations. It is widely recognized in medical and podiatric education that abundant exposure to clinical environments is essential to developing top-quality professions. The Council on Chiropractic Education requirement of 250 adjustments forces interns to use manipulation on patients whether they need it or not, and the radiographic requirement forces interns to take radiographs on patients whether they need them or not. Rather than focus on interns meeting certain numerical requirements, interns should be encouraged to develop clinical decision making and patient management skills. Further, the emphasis on achieving a certain number of procedures as opposed to the acquisition of skill and knowledge impedes the development of professional moral reasoning by training interns to use patients as a means to meet their own goals, rather than focusing on the needs of the patients themselves. The chiropractic internship should, as with medicine and podiatry, occur after graduation. Chiropractic regulatory bodies such as state boards of chiropractic medicine should move in the direction of requiring the completion of postgraduate residency training as a condition of licensure.

What this will mean for chiropractic is a giant step towards Cultural Authority and Legitimacy. It will mean a higher standard of chiropractic student (intellectually, morally & ethically) entering the State University of their choice, i.e., a real university offering transferable subject matter to any other university in the nation). It will also mean an enhanced understanding and respect between the two healthcare professions, which will then result in later professional corroboration and professional inter-referral mind-set based on mutual trust, respect and the appreciation of the individual skill-sets each practitioner brings to the table.

3) Chiropractic must seriously consider amalgamating with the physical therapy profession by means of education and attaining the Doctor of Manual Medicine (DMM) degree

Because the chiropractic profession has a very unique skill set that is desperately and immediately needed within the health care system – non-surgical spine (MSK) care – the PTs and DCs could unite forces and collectively stake a claim to all MSK care, and partition primary care into two basic categories:
(1) primary care for internal disorders which will be triaged and managed by PCPs, PAs, NPs, and DOs, and
(2) primary care for musculoskeletal disorders, which will be triaged and managed by DCs and PTs…along with some PM&R docs and DOs who have an MSK focus.

My sense is that this may be the opportunity we are missing!

It seems reasonable and pragmatic that chiropractic could change its name to “Doctor of Manual Medicine” (DMM) – remember the chiropodists with no cultural authority, who are now podiatrists with all kinds of cultural authority? – and integrate itself into a state university Doctor of Physical Therapy (DPT) program. Doctors of Physical Therapy have long enjoyed cultural authority, legitimacy and trustworthiness and, perhaps with a post-graduation residency in orthopedics (3 years), a Doctor of Manual Medicine (DMM) could be conferred? Such a paradigm shift would immediately position [chiropractic] within mainstream health care, thus affording the gratification of the cultural authority, legitimacy and trustworthiness so dearly sought after, as well as the willing and free-flow of referrals of those patients suffering uncomplicated spine & musculoskeletal injuries and/or conditions, from medical physicians, and others, to the DMM. This is, of course, dependent upon #1 above.

No matter how one looks at it, or what one would like reality to be, chiropractic medicine is about back pain, neck pain and headache. Instead of fighting that fact (or denying it), we should embrace it fully and focus on becoming society’s “go-to” profession for disorders in this area.
First, spine-related pain is one of the largest markets in all of health care. Considering neck/arm pain, back/leg pain and headache, virtually 100% of the population is potentially included [11][12] (contrast this with the fact that only 3-5% of the population currently see a chiropractor [3]).

Second, no medical specialty has successfully carved a niche for itself in this area (although the physical therapy profession is moving rapidly in this direction).

Third, spine-related disorders create a great deal of suffering on the part of patients, in addition to exacting great costs on employers, the healthcare system and society at large. Providing much-needed high quality care to individuals suffering from spinal pain, as well as initiating and taking part in public health campaigns designed to educate people about spinal pain, would be a great service to society, and would bring millions of new patients to the offices of Doctors of Manual Medicine [chiropractic], patients who would not ordinarily consider seeing a chiropractic physician.

The chiropractic profession fairly recently had a unique opportunity to catapult itself into the role of society’s non-surgical spine specialists. In 1994 the Agency for Health Care Policy and Research (AHCPR) released its guidelines on the management of acute low back pain in adults [13]. These guidelines recommended spinal manipulation as one of the only treatments for which adequate evidence existed for its efficacy. The report received a great deal of media coverage, with some media outlets actually mistakenly identifying “chiropractic”, rather than “manipulation” as the recommended first-line approach. Leadership with any vision at all could have used this as a springboard to moving chiropractic into the mainstream as the premier non-surgical spine specialists in society. However, the profession did not jump at the chance, largely, in my view, for fear of being “limited” by the image. Ironically, the profession chose to avoid being “limited” to the management of a group of disorders (back pain, neck pain and headache) that affect virtually 100% of the population through all stages of life [14]. In the interim it has seen its market share dwindle from 10% of the population [4] to less than 5% [3][15]. Even amongst patients with back pain, the proportion of patients seeing chiropractors dropped significantly between 1987 and 1997, a period of time in which the proportion seeing both medical doctors and physical therapists increased [16].
The convoluted thinking of chiropractors constantly amazes me, inasmuch as it is interesting that chiropractors have traditionally prided themselves on being “holistic”. The emerging model of modern spine care is the “biopsychosocial” model [17]. That is, it is increasingly recognized that in order to provide optimum care for patients with spine-related disorders, one has to consider the whole person. Thus, non-surgical spine care provides chiropractic medicine with a wonderful opportunity to provide truly holistic care for patients, and to be recognized for expertise in this area. This would certainly be a drastic departure from the reductionistic, subluxation-only approach, which “reduces” the cause and care of health problems to a spinal subluxation. Further, because the biopsychosocial approach often requires multidisciplinary involvement, embracing this model will further help to integrate chiropractic medicine into mainstream health care.

Certainly there is opportunity for chiropractic medicine to become what it can and should be: a profession of non-surgical spine specialists who not only offer one useful modality of treatment for spinal pain (manipulation), but offer something much greater and more important – expertise in the diagnosis and management of spinal pain patients. This includes understanding the vast mechanisms of spinal pain as well as diagnosis, treatment and coordination of the treatment with other members of the healthcare team. It also means mastering a variety of non-surgical methods other than just manipulation that are useful in the management of patients with spinal pain. But, most importantly, it means becoming experts in patient management, i.e., helping patients overcome spinal pain, whether that means providing adjustments, exercise, referral for short-term medication use and/or education regarding the issues related to LBP provided in a cognitive-behavioral context. Currently, there is no profession that adequately fills that role, although as noted earlier, the physical therapy profession is moving quickly in this direction.
The opportunity is there for us to correct our mistakes, but we must act now. The only question is whether the chiropractic profession has the integrity, vision and self-reflection required to make the necessary changes. Time will tell…..but don’t hold your breath!

References
1. Gallup poll: Americans have low opinion of chiropractors’ honesty and ethics
Dynam Chiropr 2007., 22(3):
2. Foreman SM Stahl MJ: Chiropractors disciplined by state chiropractic board and a comparison with disciplined medical physicians.
J Manipulative Physiol Ther 2004, 27(7):472-476. PubMed Abstract | Publisher Full Text
3. Keating JC Jr., Charlton KH, Grod JP, Perle SM, Sikorski D, Winterstein JF: Subluxation: dogma or science?
Chiropractic & osteopathy 2005, 13:17. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text
4. Carter R: Subluxation – the silent killer.
5. Hughes EC: Professions. Daedalus 1962, 92:655-668.
6. Nelson CF Lawrence DJ, Triano JJ, Bronfort G, Perle SM, Metz RD, Hegetschweiler K, LaBrot T: Chiropractic as spine care: a model for the profession. Chiropr Osteopat 2005, 13:9. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text
7. Mirtz TA: The question of theology for chiropractic: A theological study of chiropractic’s prime tenets. J Chiropr Human 2001., 10(1):
8. Mirtz TA: Universal intelligence: A theological entity in conflict with Lutheran theology. J Chiropr Human 1999., 9(1):
9. Seaman D: Philosophy and science versus dogmatism in the practice of chiropractic. J Chiro Human 1998, 8(1):55-66.
10. Wyatt LH Perle SM, Murphy DR, Hyde TE: The necessary future of chiropractic education: a North American perspective. Chiropractic & osteopathy 2005, 13(10):1-15. PubMed Abstract | Publisher Full Text | PubMed Central Full Text
11. Cote P Cassidy JD, Carroll LJ, Kristman V: The annual incidence and course of neck pain in the general population: a population-based cohort study.Pain 2004, 112(3):267-273. PubMed Abstract | Publisher Full Text
12. Cassidy JD Cote P, Carroll LJ, Kristman V: Incidence and course of low back pain episodes in the general population. Spine 2005, 30(24):2817-2823. PubMed Abstract | Publisher Full Text
13. Bigos S, Bowyer O, Braen G Brown K, Deyo R, Haldeman S: Acute Low Back Problems in Adults Clinical Practice Guideline Number 14 AHCPR Pub No 95-0642 Rockville, MD Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services.
14. Hartvigsen J, Christensen K: Pain in the back and neck are with us until the end: a nationwide interview-based survey of Danish 100-year-olds. Spine 2008, 33(8):909-913. PubMed Abstract | Publisher Full Text
15. Barnes PM Powell-Griner E, McFann K, Nahin RL.: Complementary and alternative medicine use among adults: United States, 2002.
Adv Data 2004, 343:1-19. PubMed Abstract | Publisher Full Text
16. Feurestein M, Marcus SC, Huang GD: National trends in nonoperative care for nonspecific back pain. Spine J 2004, 4(1):56–63. PubMed Abstract
17. Pollard H Hardy K, Curtin D: Biopsychosocial model of pain and its relevance to chiropractors. Chiropr J Aus 2006, 36(3):92-96.
18. Palmer College of Chiropractic – Identity (2013)

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You speak of Schaefer’s “Basic Principles of Chiropractic Neuroscience” – that great “scientific” text – as if it were Guyton’s Physiology! You speak of Nansel and Szlazal’s article “Somatic Dysfunction and the Phenomenon of Visceral Disease Simulation” as if it were published in the journal “Nature”, and not in that highly “respected” magazine, the “Journal of Manipulative and Physiological Therapeutics”!

You don’t seems to realize that in the world of science, and the scientific method, one cannot equate “potentialities” and “posits” with SCIENTIFIC FACT!! Your use of such words reveals your ignorance and understanding of what science really is!

“Regardless of WHAT you call that THING we adjust, there is no doubt that what we do is helpful. Over time (and with much-needed funding) researchers will help pin down WHAT it is we ADJUST”, is a statement that admits your being trapped by the Post hoc ergo proper hoc fallacy, and that there is no such thing as a subluxation, inasmuch as you now concede, “Over time (and with much-needed funding) researchers will help pin down WHAT it is we ADJUST”.Thus,you admit that we don’t know whether the subluxation exists or not, BECAUSE we need time and much-needed funding for researchers to find out WHAT it IS we adjust!

You just KNOW that “it” works because it works…and that’s that!
“A” caused “B” because “A” occurs before “B”!!!!!!!!

What convoluted unscientific thinking!

So I’ll just go along my “merry” way with those pragmatic, realistic, intelligent and forward thinking CONVERTS, such as: Foreman,Perle, Winterstein, Nelson, Haldeman, Sportelli, Schneider, Triano, Cassidy, Brontfort, Mertz, Seaman, Murphy, Hyde, Christensen, Goertz, Haas, Edwards, Lbouef, Phillips, etc., etc., etc.,etc…..!